How are we responding to the opioid crisis?

By: Margaret C. Tracci, MD, JD

The Scale of the ProblemOpioids Cartoon

Over the past two decades, the abuse and diversion of prescription opioids has grown to epidemic proportions. In 2009, fueled by a surge in deaths associated with prescription pain medications, drugs deaths outnumbered traffic fatalities for the first time. Just a few weeks ago, the Council of Economic Advisors released a report estimating that the economic cost of the opioid crisis was $504 billion, or 2.8% of GDP in 2015, the last year for which complete data were available.

The Federal Response

So what has the federal government done to respond to this crisis?  In October, the Department of Health and Human Services declared the opioid crisis a public health emergency.  In FY2017, HHS invested nearly $900 million in opioid-specific programs, including funds authorized through the Comprehensive Addiction and Recovery Act of 2016 (CARA) and the 21st Century Cures Act and the Department of Justice granted nearly $60 million. Much of this funding supports the efforts of state and local governments. Beyond funding, the federal government has established broad education effort aimed at both providers and the public. It has also sought to support the development and promulgation of best practices, including the Centers for Disease Control and Prevention’s 2016 release of the CDC Guideline for Prescribing Opioids for Chronic Pain.

States Take Up the Call to Legislate

The legislative response of the states to this crisis has spanned both health care and law enforcement and spawned a great deal of innovation. On the health care front, we have seen the rapid passage of laws supporting treatment and recovery services, improving the availability of overdose reversal drugs and training first responders in their use, strengthening data reporting and collection, and underwriting research on addiction, pain, and best medical practices. States have also moved rapidly to establish prescription monitoring programs (PMPs) to reduce “doctor shopping” behavior and have, increasingly, mandated that providers access these programs when prescribing opioids. More recently, states, including Virginia, have embraced the adoption of strict limitations on prescribing and mandated opioid-focused CME.

Law enforcement has moved beyond early efforts aimed at reducing the supply of opioids through interdiction of illicit trafficking to innovative approaches such as take-back and disposal programs and dedicated “drug courts” intended to divert those suffering from addiction toward needed services and support rather than prison, including programs targeting youth, families, and veterans.  The Veterans Treatment Courts perhaps go the farthest in bridging the law enforcement-health care divide by approaching this population with an understanding of the strong relationship between substance abuse and mental health disorders, using Outreach Specialists with access to medical records and the ability to make appointments, and integrating criminal justice with access to treatment and mentoring programs. Virginia’s drug courts, such as those in Charlottesville/Albemarle, are striving for a similar coordination of criminal justice and access to treatment and social services, though they rely on a mélange of funding through a blend of federal grants, state sources, and local matching funds, as do their partner local Community Service Boards (CSBs). These challenges persist despite cost-benefit analyses suggest substantial cost savings when offenders participate in drug treatment programs rather than standard court and annual reviews consistently demonstrating lower recidivism rates in those who complete diversion programs.

What’s Happening in Virginia?

Virginia has been hard hit, with a steady rate of approximately 5 deaths per 100,000 attributed to prescription opioids and a skyrocketing rate of deaths due to fentanyl or heroin overdose.  While fentanyl (synthetic opioid) and heroin deaths are clustered in urban areas, prescription opioid-related mortality plagues the economically depressed rural areas of the state, particularly along the Eastern Shore and Appalachian regions. Echoing national figures, drug overdoses overtook motor vehicle crashes and gunshots as the leading cause of unnatural death in 2014. More than 10,000 Virginians are now brought to the ED annually for opioid overdoses. Associated with this are a steady increase in the rate of neonates suffering from withdrawal, known as neonatal abstinence syndrome (NAS), and young adults infected with Hepatitis C, which can lead to cirrhosis, cancer, liver failure, and death. ()

OpioidsVirginia’s health care leaders led the federal government in declaring the opioid crisis a public health emergency. As the federal response has ramped up with funds authorized under CARA, the 21st Century Cures Act, and the 2017 Omnibus Appropriations bill, Virginia’s state government, localities, researchers, and providers have proven eager partners.  The State received $9.7 million under the first round of funding authorized by the 21st Century Cures Act, to support medication-assisted treatment (MAT) for addiction and to purchase the overdose-reversal drug naloxone. In 2017, other Virginia awardees have been granted over $1 million authorized under the CARA and administered by SAMHSA to support a pilot project for the treatment of pregnant and postpartum women, $596,000 through the U.S. Department of Justice’s Bureau of Justice Assistance to enhance collaboration between criminal justice and health agencies, funding directed to support the PMP, drug courts, CSBs, and multiple researchers.

True to form, Virginia has also tapped native talent to seek innovative solutions. Governor McAuliffe convened, in September, an Opioid Addiction Crisis Datathon with a stated goal of “using data to disrupt” Virginia’s opioid crisis. Groups ranging from consulting groups Kearney & Co and PricewaterhouseCoopers (PwC) to university groups from the University of Virginia (UVA) and Virginia Commonwealth University (VCU) to the Virginia Department of Health (VDH) and even the Virginia Department of Transportation (VDOT) participated. Common issues were identified, including the failure to connect those at risk with available resources, resulting in millions of dollars left on the table each year. Solutions included the use of sociodemographic data to target areas of need, development of tools to permit accurate risk stratification to drive intervention, interventions to prevent drug use in at-risk adolescents.

What Should We Be Watching?

Of great concern within the healthcare community is the growing understanding that a significant subset of those who develop opioid use disorder first encounter these drugs through legal prescriptions for pain medications following an injury, surgery, or similar condition. Among heroin abusers, the CDC reports that three out of four previously abused prescription pain medications.  Providers are redoubling efforts to address their role in the crisis. Surgeons, anesthesiologists, and nursing specialists have targeted areas of high opioid utilization, such as the perioperative and postoperative period, and developed protocols to use patient education and non-opioid pain management to drastically reduce the use of opioids after surgery while also reducing cost and improving outcomes and patient satisfaction. Dedicated providers and researchers continue to delve into the social and biological basis for substance abuse and the development novel medical and behavioral interventions.

While the regulation of pain clinics, the establishment of PMPs, provider education, and the adoption of legislation limiting the prescribing of opioids have shown promise in reducing excessive opioid prescribing, providers and patient advocates have also warned that there is a fine balance between limiting opioid use and raising barriers to the treatment of pain. Careful attention must be paid, going forward, to both the positive and, potentially, negative impacts of legislation.

Finally, while the urgency of the opioid crisis is broadly understood, there is much to be learned about the effectiveness of various interventions. At the moment, the future of funding of these efforts, not to mention health care and the federal government, itself, remains in flux. In this setting, it will be more important than ever to understand what works, what doesn’t, and how to most effectively channel limited resources to impact this growing crisis.

Actions Have Consequences: The 2018 ACA Open Enrollment

By: Carolyn Long Engelhard, MPA

Open Enrollment ImageToday marks the beginning of the fifth enrollment period for the availability of health coverage under the Affordable Care Act (ACA).  For the first time since the passage of President Obama’s signature legislation in 2010, this year’s open enrollment period will be administered under a Republican administration that holds little love for the law.  After a tortured summer of unsuccessfully trying to repeal the ACA in Congress, President Trump and officials at Health and Human Services (HSS) are now moving to a “Plan B” strategy of using administrative strategies to weaken the legislation.  These tactics include shortening the enrollment period in half to 45 days, eliminating almost all funding for health plan marketing and consumer outreach, defunding cost-sharing reductions for low-income enrollees, and pursuing executive orders that hold the promise of destabilizing insurance risk pools and reducing insurer participation.  These actions have consequences.  Whether individuals plan to renew insurance plans from last year or join the ACA market anew, this year’s enrollment experience will offer many new challenges.  These include:

A greater sense of confusion about the status of the ACA.

According to the Kaiser Family Foundation, only 59% of uninsured people between 18 and 64 are aware that the penalty for not having insurance is still in effect.  Eighteen percent of the uninsured think the penalty no longer exists and 23 percent are unsure.  This confusion, stirred up by political attacks on the viability of the ACA, suggests that enrollment will be lower than last year.  The fact that the Trump Administration plans to spend 90% less on advertising and outreach this open enrollment season only accentuates the possibility of fewer sign-ups.

Widely variable insurance premium rates.

Health insurers factored in premium increases from 7 percent to 38 percent in ACA plans to compensate for the loss of cost-sharing reduction payments from the federal government.  Benchmark “silver” plans on the ACA market will rise 34 percent on average.  How individual consumers are affected by the premium increases depends on the size and amount of the premium surcharges states used to offset the loss.  The 84 percent of ACA enrollees who receive tax credits to defray the cost of insurance will not see substantial spikes in their premiums in 2018, but the 7 million middle- and upper-income people purchasing non-group insurance who are ineligible for subsidies will experience double-digit increases.  These increases will come as an unwelcome surprise to many former enrollees and almost certainly will suppress the number of Americans who receive coverage.

Assignment to a health plan by default.

In past years, nearly 25 percent of people (2.8 million in 2017) who enrolled in ACA plans used the auto-renewal function to remain in the plan they chose the year before.  However, many health insurers plan to exit the ACA market after the 2017 year because of the continued uncertainty surrounding the fate of the ACA and the discontinuation of cost-sharing transfers to insurers.  As a result, auto-renewal mechanisms may end up placing consumers in different plans.  In the past, enrollees could count on having time to review the auto-renewal assignments and make changes to uphold preferred provider networks or drug formularies.  However, since the open enrollment period for 2018 has been shorted by half, enrollees may not have time to choose an alternate plan if they do not like the auto-renewal substitution.

All of these changes suggest a very rocky roll-out for ACA insurance coverage next year and foreshadow a decline in enrollment.  Those who cannot afford stiff premium increases will join and add to the ranks of the 30 million uninsured.  As more Americans confront the emotional anxiety of losing coverage to affordable health care, those who serve them – safety net providers like UVA – also will struggle to meet the demands of increasing levels of uncompensated care.  This is particularly true in states like Virginia, who opted not to expand their Medicaid program under the ACA, and for those states with large populations of low- to middle-income folks.  In those states, there will be fewer plans available for individual coverage and much higher premiums in the ones that are.  Ironically, these are the states that delivered landslide victories to the president.  Now, it appears, they may be the ones to suffer most by his actions.

Maya Wright Receives Global Health Grant

Maya Wright is a rarity:­ a woman in the STEM (science, technology, engineering and math) field. Rarer still, she is an African-American woman in the STEM field.

In 2014, the National Science Board’s annual “Science and Engineering Indicators” report found African-Americans, Hispanics, American Indians and Alaska Natives collectively make up 26 percent of the U.S. population age 21 and older, but accounted for only 10 percent of the United States’ science and engineering workers in 2010.

A new, million-dollar-plus program at the University of Virginia aims to make Wright’s distinction less distinctive. Wright is one of the first recipients of a grant from the Minority Health International Research Training program, created to support outstanding, underrepresented minority students in the field of global, rural health. U.Va.’s Center for Global Healthselected nine grant recipients this spring from a national pool of candidates. Some will spend the summer working in St. Kitts and Nevis on diabetes treatment; Wright is returning to Limpopo, South Africa, at the end of the month. She fell in love with the region and public health in the summer of 2013, when she was there on a Water, Society and Health Research Experience for Undergraduates grant.

The Echols Scholar, who graduated from the University on Saturday with a degree in neuroscience, sat down with UVA Today to talk about her transition from the lab to the field.

Q. How did you get interested in public health?

A. I knew I always liked science, but being in the lab just wasn’t for me. I didn’t know there were research opportunities outside the lab. Then I heard about the Research Experience for Undergraduate grants. They are mainly for science majors, so science, mathematics ─ the STEM field. I applied and was so excited when I got it.

I worked in South Africa handing out clay water filters as part of U.Va.’s  PureMadiproject and found out what public health was. I could do research outside of the lab and I was interacting with people and I just really loved it. I realized this is where I needed to be. I want to be doing this kind of work, globally, for the rest of my life.

Q. You worked in Limpopo Province for eight weeks between your second and third years. Can you describe the communities you worked in?

A. We were working in very rural villages and people didn’t speak English. I never really knew what poverty was until I was in these villages. There were dirt roads. Not every house is accessible by car. It is very hilly and people walk everywhere. A lot of the homes are made from clay and dirt with grass roofs. Some are nothing more than aluminum shacks and all of the restrooms are outside. There is no indoor plumbing. This was 2013 and people still didn’t have clean running water in their homes. It really boggled my mind.

Even though there was poverty, it was a rich place, too. People were welcoming and friendly. Even though they were poor, they were surviving and thriving. I loved it and knew I wanted to go back.

Q. You said you were the only African-American student on your first trip to South Africa. What was that like?

A. For me, when you are an American and you are black, you don’t feel completely American. But you’re not African. You are kind of in this middle area. When I was in Africa, I was very aware that I was not African, but I was still black. I was trying to figure out where I fit in. But I really enjoyed my experience and I learned a lot. I guess I just decided that I am a citizen of the world and I would find my home wherever I go.

Q. What will you be doing in Limpopo this summer?

A. After my first visit to South Africa I knew I wanted to go back right away. But I knew I couldn’t afford it. Dr. Dillingham encouraged me to apply to the Minority Health International Research Training program. The research project in South Africa will focus on working with community health workers to better deal with hypertension and traditional medicine and the treatment of HIV. As the graduate student mentor, my job is to help along the undergraduates with their research, be a facilitator between them and their Ph.D. mentors from the University of Venda and to help them to engage the culture and the people. I really want to make sure that they have as good an experience as I did.

I will be mentoring three women and one man. They are from all over the country. One is from Virginia Tech, one is from the University of Washington, one is from Harvard and one is from U.Va. They are all amazing people, ranging from freshman to juniors. They are all African-American. Everyone is bringing something different to the experience and I’m really excited to work with them.

Story originally published in UVAToday

Life-Saving Drugs Untaken in Appalachia

Nearly a third of breast cancer survivors in Appalachia are not taking the critical, potentially life-saving follow-up treatment – despite having insurance that would pay for it, a troubling new study has found.

Researchers cross-examined cancer registries with Medicare claims data and determined that of 428 women, approximately 30 percent failed to follow through with their prescribed adjuvant hormone therapy, a treatment to prevent the cancer’s recurrence.

“Almost a third of the prescriptions for adjuvant hormone therapy were not filled, which is much, much higher compared to what we usually see in commercially insured populations,” said Rajesh Balkrishnan of the University of Virginia School of Medicine’s Department of Public Health Sciences. “Usually it ranges from about 10 [percent] to 15 percent, so this is almost double that. A third of the women going without adjuvant hormone therapy – that is a scary prospect.”

Read full article here:

Stephen Rich, PhD, Wins JDRF’s Rumbough Award

Renowned genetic epidemiologist Stephen Rich, PhD, director of the University of Virginia Center for Public Health Genomics, has been honored with one of the Juvenile Diabetes Research Foundation’s (JDRF) most prestigious awards, the David Rumbough Award for Scientific Excellence.  The award recognizes pioneering scientists who have made outstanding contributions to diabetes research.

A world leader in the fields of molecular epidemiology and genetics, Dr. Rich’s long-term interest in the genetic basis of type 1 diabetes has led to the identification of more than 40 regions in the human genome that contain genes affecting type 1 diabetes risk.

“The scientists who received these awards represent the best and the brightest, and are the embodiment of the hope and commitment each and everyone of us has that treatments will soon be a reality, and that a cure is inevitable,” says Dr. Richard Insel, executive vice president of research at JDRF. Awards were presented May 21, 2010 during JDRF’s Annual Conference in Washington, D.C.

Dr. Rich leads a team of UVA investigators who are working to translate findings from the Human Genome Project into usable science and treatments to benefit type 1 diabetics. His team is identifying potential genetic biomarkers that can be useful in assessing risk for developing the disease and its complications. Rich also heads the National Institutes of Health Type I Diabetes Genetics Consortium, an international effort to understand the genes that underlie diabetes and its complications.

Established almost 40 years ago by actress Dina Merrill in honor of her late son, David, the Rumbough Award is presented annually in recognition of outstanding achievement in diabetes research and service to JDRF.

In addition to Dr. Rich, recipients of the 2009 David Rumbough Award for Scientific Excellence are: Dr. Gerald Nepom, director of the Benaroya Research Institute at Virginia Mason and the JDRF-BRI Center for Translational Research in Seattle, Wash.; and Dr. Anne Marie Schmidt, chief of the Division of Surgical Science and the Gerald and Janet Carrus Professor of Surgical Science at Columbia University.

TV: Obesity in an Hour

Watching television as little as an hour a day are significantly more likely to be overweight or obese and gain more unhealthy weight over time, according to a new study from the School of Medicine. Based on the findings, the researchers say physicians should encourage families to restrict young children’s TV viewing to prevent unhealthy weight gain.

Television and children

Many previous studies that have examined the link between television and childhood obesity evaluated the effects of watching at least two hours a day; the UVA researchers, on the other hand, wanted to determine how smaller amounts would affect children in kindergarten and first grade. Their findings were troubling: Compared with children who watched less than an hour of TV on weekdays, children who watched 1-2 hours were 1.4 times more likely to be overweight and up to 1.5 times more likely to be obese.

Further, children of a healthy weight who watched more than an hour a day were much more likely to become obese: Such children had 1.39 times the odds of becoming overweight and 1.86 times the odds of becoming obese.

“We were interested to see that children watching only one to two hours of TV already had almost the same degree of unhealthy body weight as those watching more than two hours,” said Mark D. DeBoer, MD, of the UVA Department of Pediatrics, who led the research. “These data support the notion that even lower amounts of TV viewing are associated with unhealthy weight gain.”

Healthy limits on TV

The American Academy of Pediatrics recommends children watch no more than two hours of television daily. But DeBoer argues even that may be too much. “Based on the results of our study, we would recommend no more than one hour of TV daily. We recommend that parents place limits on how much TV their children watch and replace viewing time with opportunities for physical activity and educational activities. This may require supporting parents through increased funding for safe play and educational locations such as parks and libraries.”

In conducting the study, DeBoer and his colleagues examined data from a nationally representative sample of more than 14,000 children, collected as part of the Early Childhood Longitudinal Study-Kindergarten Cohort 2011. TV viewing increased with lower parental education and household income; the findings of the study persisted after adjustment for these and other possible confounding factors.

Findings presented

DeBoer presented his findings Sunday at the Pediatric Academic Societies’ annual meeting in San Diego. The findings also will appear as a paper in the journal Obesity. The first author was Travis Peck, a third-year medical student at UVA, and the other authors were Rebecca J. Scharf, MD; Mark Conaway, PhD; and DeBoer.